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Example ClinicalImpression/example (Turtle)

Patient Care Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Encounter, Patient, Practitioner

Raw Turtle (+ also see Turtle/RDF Format Specification)

Example of clinicalimpression

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

[a fhir:ClinicalImpression ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "example"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClinicalImpression</b><a name=\"example\"> </a><a name=\"hcexample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ClinicalImpression &quot;example&quot; </p></div><p><b>identifier</b>: 12345</p><p><b>status</b>: completed</p><p><b>description</b>: This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident</p><p><b>subject</b>: <a href=\"patient-example.html\">Patient/example</a> &quot;Peter CHALMERS&quot;</p><p><b>encounter</b>: <a href=\"encounter-example.html\">Encounter/example</a></p><p><b>effective</b>: 2014-12-06T20:00:00+11:00 --&gt; 2014-12-06T22:33:00+11:00</p><p><b>date</b>: 2014-12-06T22:33:00+11:00</p><p><b>performer</b>: <a href=\"practitioner-example.html\">Practitioner/example</a> &quot;Adam CAREFUL&quot;</p><p><b>problem</b>: <span>: MVA</span></p><p><b>summary</b>: <span title=\" \n   &lt;investigation&gt;\n    &lt;code&gt;\n      &lt;text value=&quot;Initial Examination&quot;/&gt;\n    &lt;/code&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;deep laceration of the scalp (left temporo-occipital)&quot;/&gt;\n    &lt;/item&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;decreased level of consciousness&quot;/&gt;\n    &lt;/item&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;disoriented to time and place&quot;/&gt;\n    &lt;/item&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;restless&quot;/&gt;\n    &lt;/item&gt;\n  &lt;/investigation&gt;\n   \">provisional diagnoses of laceration of head and traumatic brain injury (TBI)</span></p><blockquote><p><b>finding</b></p><h3>Items</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Concept</b></td></tr><tr><td style=\"display: none\">*</td><td>850.0 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (ICD-9#850.0)</span></td></tr></table></blockquote></div>"
  ] ; # 
  fhir:identifier ( [
     fhir:value [ fhir:v "12345" ]
  ] ) ; # 
  fhir:status [ fhir:v "completed"] ; # 
  fhir:description [ fhir:v "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident"] ; # 
  fhir:subject [
     fhir:reference [ fhir:v "Patient/example" ]
  ] ; # 
  fhir:encounter [
     fhir:reference [ fhir:v "Encounter/example" ]
  ] ; # 
  fhir:effective [
     a fhir:Period ;
     fhir:start [ fhir:v "2014-12-06T20:00:00+11:00"^^xsd:dateTime ] ;
     fhir:end [ fhir:v "2014-12-06T22:33:00+11:00"^^xsd:dateTime ]
  ] ; # 
  fhir:date [ fhir:v "2014-12-06T22:33:00+11:00"^^xsd:dateTime] ; # 
  fhir:performer [
     fhir:reference [ fhir:v "Practitioner/example" ]
  ] ; # 
  fhir:problem ( [
     fhir:display [ fhir:v "MVA" ]
  ] ) ; #    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)   
  fhir:summary [ fhir:v "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"] ; #   
#   <investigation>
#    <code>
#      <text value="Initial Examination"/>
#    </code>
#    <item>
#      <display value="deep laceration of the scalp (left temporo-occipital)"/>
#    </item>
#    <item>
#      <display value="decreased level of consciousness"/>
#    </item>
#    <item>
#      <display value="disoriented to time and place"/>
#    </item>
#    <item>
#      <display value="restless"/>
#    </item>
#  </investigation>
#    
  fhir:finding ( [
     fhir:item [
       fhir:concept [
         fhir:coding ( [
           fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-9"^^xsd:anyURI ] ;
           fhir:code [ fhir:v "850.0" ]
         ] )
       ]
     ]
  ] )] . # 

# -------------------------------------------------------------------------------------


Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.